A mother reports that her 3-month-old son is fussy and has had a runny nose and fever for the past 5 days. She also notes that the infant developed a red, raised rash initially on his face, which spread to his abdomen and extremities over the course of a day. The mother reports that her son is eating less and has been breathing rapidly. The boy was born full-term in the United States and has no past medical history. He has had 1 vaccination at his primary care physician, at 2 months of age. The family just returned from a trip to London a week ago, and there are no other sick contacts in the family. The infant’s vital signs are: heart rate, 175 beats/min; respiratory rate, 45 breaths/min; rectal temperature, 38.3oC (101oF); and oxygen saturation, 91% on room air. The physical examination findings demonstrate bilateral conjunctival injection with no purulent drainage, rhinorrhea, and slightly dry lips and oral mucosa. The infant has a blanching maculopapular exanthem to his face, trunk, extremities, palms, and soles. Upon auscultation, he has rales at both lung bases.
A 6-month-old girl, who was born full-term, is brought into the ED by her mother. The mother states that her daughter has had a fever and a rash for 3 days; the rash began on the infant’s face as “water blisters." The mother also states that her daughter has not felt well for the last 2 days, has had decreased urine output, decreased activity, and has been irritable. According to the mother, the girl is up to date with recommended vaccinations for her age. There are no sick contacts in the family; however, the patient’s grandmother has a painful rash on her back. The infant’s vital signs are: heart rate, 170 beats/ min; respiratory rate, 25 breaths/min; rectal temperature, 38.5oC (101.4oF); and oxygen saturation, 98% on room air. The physical examination is significant for vesicles on an erythematous base on the girl’s face, trunk, extremities, and back, as well as many excoriated and scabbed lesions. There are erythematous papules on the anterior buccal mucosa and the posterior pharynx. The infant’s mucous membranes are dry, her lungs are clear, and her skin is warm. The infant is crying and her mother is having difficulty consoling her.
What is the etiology for these patients’ fever and rash? What are the possible complications of their illnesses? Do these patients need any diagnostic testing or specialty consultation? Should these patients be isolated in the ED? What treatments are indicated? Should these patients be admitted? Should their contacts be isolated or treated?
Vaccine-preventable diseases such as measles, mumps, rubella, and varicella continue to afflict children in the United States and abroad. The estimate of global vaccine coverage is approximately 84% for these 4 diseases. As of 2014, 29% of the World Health Organization (WHO) member states (57 countries) administer the measles vaccine. In 2013, approximately 21.5 million children did not receive the first dose of the measles vaccine, and 60% of these children were from 6 countries—India, Nigeria, Pakistan, Ethiopia, Indonesia, and the Democratic Republic of the Congo.1 Even in industrialized countries with national vaccination guidelines (eg, the United States), vaccination coverage for measles, mumps, rubella, and varicella in school-aged children is not complete.2 Vaccine failures, waning immunity, vaccine rejection, and public fear have led to community outbreaks and clinical sequelae in those exposed and affected. This issue of Pediatric Emergency Medicine Practice will summarize these 4 formerly common childhood diseases that can be prevented with vaccination, but may still sporadically occur. This information will enable emergency clinicians to effectively recognize children with these diseases to ensure appropriate treatment and decrease their spread.
A literature search was performed in PubMed, using the search terms measles, mumps, rubella, varicella, vaccine-preventable, and disease outbreaks. The Cochrane Database of Systematic Reviews was searched using the terms measles, mumps, rubella, varicella, and vitamin A. The United States Centers for Disease Control and Prevention (CDC) and the WHO websites were searched for relevant materials, including recent epidemiological data. Most data about these diseases are from case series and epidemiological reports.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
Money-back GuaranteeDeborah A. Levine, MD
December 2, 2016
January 2, 2020
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